Rx for a Better Night’s Rest

by Edward Stepanski, PhD

Difficulty sleeping, or insomnia,
is a frequent problem for people
being treated for cancer.
People experience insomnia in many
different ways: trouble falling asleep at
the beginning of the night, waking up
in the middle of the night and being
unable to return to sleep, or having
many brief awakenings throughout the
night, leading to unrefreshing sleep.

Insomnia generates many possible
daytime consequences, including fatigue,
decreased concentration and memory,
increased depression, and increased
perception of pain. In addition to these
direct effects of insomnia, a potential
indirect effect is a reduction in the ability
to engage in cancer treatment. A rested
person is in a
better position
to endure the
rigors of cancer
treatment. Since
there are safe
and effective
treatments for
insomnia, seeking
treatment is
appropriate for
anyone experiencing
daytime impairment related
to insomnia.

Treatment for insomnia can be in the
form of medication (e.g., sleeping pills)
or cognitive-behavioral treatment (CBT).
CBT requires adjusting habits that can
affect how well you sleep. In general,
medication is recommended for short-term,
or transient, insomnia, and CBT
should be used for long-term, or chronic,
insomnia. For example, medication
would be best for someone who is
anxious about upcoming surgery and
develops insomnia related to that anxiety.
Medication can be used to allow
improved sleep prior to surgery and
then discontinued afterward.

A rested person is in a better position to endure the
rigors of cancer treatment.

Dr. Edward Stepanski

Although sleeping pills have gotten
a bad reputation due to the risk of dependence,
they are often appropriate
and effective, especially when used for
short periods. Short-acting medications
are preferred as they increase the ability
to sleep during the night but do not continue
this effect into the day.

Several research studies have shown
that CBT improves sleep in people with
insomnia who have been diagnosed with
cancer. The ability to attain restful sleep
is related to many habits, such as keeping
a regular sleep/wake schedule, taking
naps during the day, consuming caffeine
or alcohol, and worrying about
sleep quantity or quality.

When people become ill, they commonly
change many of their habits,
including their sleep-related habits. For
example, a person on medical leave from
work may stay in bed later in the morning
while keeping the same bedtime at
night. This simple change means the
total time in bed may go up to nine or
ten hours, but the quantity of sleep may
stay the same. The person may be sleeping
seven or eight hours each night but
will spend two to three hours awake
during the night. Because of the time
spent awake, this person is more likely
to get out of bed, get something to eat,
check e-mail, or engage in other activities,
further worsening his or her quality
of sleep. As time goes on, this person
will begin to worry about his or her
lack of sleep, which can lead to increased
tension at night and poorer sleep quality.

In this example, a simple change in
arising time leads to a cascade of additional
changes that will likely end in
disrupted sleep. This is why adopting
good sleep habits is important in solving
a problem with insomnia.

Choosing between sleeping pills and
CBT can be complicated for a person
being treated for cancer. For instance,
a person receiving chemotherapy may
experience extreme fatigue and other
symptoms that would make it difficult
to seek out a sleep specialist or to follow
a CBT program. Therefore, administering
sleeping pills might be the preferred
method of improving sleep during
cancer treatment, and CBT could be
implemented after completing chemotherapy
if the insomnia returns.

There is no single approach to dealing
with insomnia. The best treatment
will depend on individual aspects of the
problem. Perhaps the most important
factor is the severity of insomnia-related
impairment during waking hours. For
example, if a person notes substantially
increased pain on days following very
poor sleep, the advantages of using
sleeping pills – improved pain control
and decreased use of pain medication
during the day – may outweigh the possible
side effects.

If you are struggling with insomnia,
you should discuss it with your doctor
so, together, you can create a treatment
plan that works for you.

♦ ♦ ♦ ♦ ♦

Dr. Edward Stepanski is chief
operating officer for the Accelerated Community
Oncology Research Network in
Memphis, TN.

For a list of certified specialists
in CBT for insomnia, visit the American
Academy of Sleep Medicine Web site, http://aasmnet.org.